Category Archives: "Articles"

Diabetes Mellitus Coding Guidlines

Diabetes Mellitus Coding Guidelines
Sommer Huseman, RN, Risk Adjustment and Coding Specialist

Diabetes mellitus is a condition that results when the body is unable to produce enough insulin or properly use the insulin that it does produce. The disease of diabetes is present in a significant number of patients and consumes more than $100 million in health care resources in the United States. Therefore, it is important that the guidelines for coding diabetes mellitus are understood. Correct coding of diabetes is…

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Put MEAT in Documentation for Healthy Audits

Put MEAT in Documentation for Healthy Audits

Submitted by: Angie Hlad, CRN-C, Risk Adjustment and Coding Coordinator

Complete and accurate documentation is the key for impacting quality, safety, efficacy, and data integrity.  Additionally, complete and accurate documentation helps safeguard against payment recovery from Medicare in an audit situation.

Medicare wants to ensure payments to PACE organizations match the expected costs of care.  In order to accomplish this, CMS scrutinizes health plans with both random and targeted audits for validity of diagnoses submitted.  …

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CMS Requirements for Monitoring and Auditing

CMS Requirements for Monitoring and Auditing

Submitted by: Matt Zimmerman

The importance of developing and maintaining a robust Internal Monitoring and Auditing Program focused on adhering to PACE guidelines cannot be underestimated. Plans that have a strong program in place are assured in knowing that they are within the regulations and experiencing the reassurance that compliance adherence affords. Plans on the other side of the spectrum are plagued with the stress and worry that comes with either not knowing if they…

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Correcting Diagnosis Codes Submitted for Risk Adjustment (RAPS) -Part 2

Capstone LogoCorrecting Diagnosis Codes Submitted for Risk Adjustment (RAPS) -Part 2

By: Dr. Richard Schamp, MD

Our previous article described the importance of identifying and correcting errors in submitted data such as RAPS files.  Today, we review how to correct the errors.

The Risk Adjustment Processing System at CMS allows for the correction of risk adjustment data submitted to CMS. This correction process is based on the concept that the incorrect…

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Correcting Diagnosis Codes Submitted for Risk Adjustment (RAPS) – Part 1

Capstone LogoCorrecting Diagnosis Codes Submitted for Risk Adjustment (RAPS) -Part 1

By: Dr. Richard Schamp, MD

PACE Organizations (POs) face many compliance issues regarding their data submissions to regulatory agencies.  Risk Adjustment data is just one of the many areas where care is needed.  For example, POs are required to attest annually regarding risk adjustment data accuracy.

  • MA plans must certify that risk adjustment data is accurate, complete and truthful (based…

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Risk Adjustment Data Validation (RADV) Guidelines for Medical Record Documentation

Written by: Dr. Richard Schamp, CEO

The Centers for Medicare and Medicaid Services (CMS) perform risk adjustment data validation audits on patients’ medical records. Risk adjustment data validation (RADV) is the process of verifying diagnosis codes submitted for payment are supported by medical record documentation. The purpose is to ensure risk adjusted payment integrity and accuracy.  CMS has announced its intention to increase auditing activity consistent with an emphasis to reduce payment errors.

Signs your plan may be at risk for…

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Capstone Performance Systems selected to provide training for National PACE Association members

BOULDER, Colo.–May 8th, 2013–The National PACE Association (NPA), which represents Programs of All-inclusive Care for the Elderly (PACE) nationwide, has made an agreement with Capstone Performance Systems (Capstone) to provide assistance to NPA members. Specifically, Capstone will provide training and resources for documentation and coding procedures that will be integral to the full implementation of CMS Encounter Data Reporting System (EDRS) for PACE organizations in 2014.

Regulated by Centers for Medicare and Medicaid Services and state Medicaid agencies, PACE organizations…

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